Provider First Line Business Practice Location Address:
5500 EAST LOMBARD STREET
Provider Second Line Business Practice Location Address:
ROOM 1025
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-550-0112
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/27/2019